The Egyptian Journal of Medical Human Genetics (2016) 17, 125–129 HOSTED BY Ain Shams University The Egyptian Journal of Medical Human Genetics www.ejmhg.eg.net www.sciencedirect.com CASE REPORT Opitz C syndrome: Trigonocephaly, mental retardation and craniofacial dysmorphism J.A. Avina Fierro a,*, D.A. Hernandez Avina b a Pediatric Dysmorphology, IMSS Medical Center Guadalajara, Mexico b Emergency Department, IMSS General Hospital 2, Aguascalientes, Mexico Received 24 April 2015; accepted 3 May 2015 Available online 9 June 2015 KEYWORDS Abstract We describe a 4-year-old female child with a dysmorphic and neurological syndrome of Trigonocephaly; trigonocephaly, mental and psychomotor retardation and dysmorphic facial features. The anoma- Facial dysmorphism; lies of the face were the following: slight upward palpebral fissures, ocular hypertelorism, depressed Balanced translocation nasal bridge, hypoplastic nasal root, short nose with anteverted nares; small low set ears, smooth broad philtrum and thin upper lip. The patient had important cerebral anomalies with diffuse alter- ations in white matter that caused developmental delay with verbal and nonverbal disabilities and severe learning difficulties. This clinical presentation is compatible with the diagnosis of the Opitz C syndrome, a heterogeneous disease of multiple neurological and craniofacial abnormalities. The physical sign more detectable and notorious is the trigonocephaly that is manifested by a prominent metopic suture, but also can be distinguished the other minor facial anomalies that are found in the eyes, nose, mouth and ears that constitute the phenotype of the disorder. The neurological devel- opment was altered by the compression of the cerebral frontal lobes with narrowing of this cerebral area, producing hypotonia with muscle weakness, epileptic episodes manifested by seizures, and neurobehavioral and neurocognitive disorders. This syndrome is a very rare genetic disorder with autosomal recessive inheritance trait; our patient had no chromosomal abnormality in the usual karyotype but the fluorescence in situ hybridization (FISH technique) showed a balanced translocation between the chromosomes two and eleven: t(2:11) (q32.2/q24). Ó 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Ain Shams University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction forehead as seen from top view. This is a sporadic condition in the majority of nonsyndromic cases, but that can be seen The trigonocephaly is the manifestation from an abnormal like the most important sign along other genetic syndromes synostosis in the metopic suture, it is a triangular shaped [1] and this cranial characteristic is the main phenotypic fea- ture of Opitz C syndrome. This was first described in 1969 * Corresponding author. when Opitz evaluated an affected family: one brother and E-mail address: avinafi[email protected] (J.A.A. Fierro). one sister with trigonocephaly, unusual faces and severe men- Peer review under responsibility of Ain Shams University. tal retardation; both patients showed trigonocephaly by the http://dx.doi.org/10.1016/j.ejmhg.2015.05.006 1110-8630 Ó 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Ain Shams University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 126 J.A.A. Fierro, D.A.H. Avina prominent metopic suture by abnormal craniosynostosis [2]. pattern showing hypsarrhythmia with high disorganized and the name with the ‘‘C’’ originated from the surname of this chaotic brain-wave; it was prescribed anticonvulsant medica- family, hence the eponymous name ‘‘Opitz C syndrome’’. tion: vigabatrin and valproate to obtain the control of the sei- Fewer than 60 cases have been reported in the worldwide liter- zures. A cranial CT scan demonstrated a sharp angle and keel ature [3]. Since almost all the patients have genetic etiology shape on the fronto-orbital area, leukodystrophy, demyelina- from de novo mutations in sporadic cases, it is suggested that tion and hypodense lesions at the subcortical areas in both the syndrome may be cytogenetically undetectable in the usual hemispheres but mainly at occipital lobe and external capsule karyotype because the existence of a small microdeletion is of basal ganglia; and there was significant hypomyelination only observed with the fluorescence in situ hybridization of the periventricular white matter (Fig. 1). (FISH technique). Today the patient is 4-years-old, and now the physical The premature closure of the metopic suture results in a examination reveals proportionate short stature with the fol- growth restriction of the frontal bones, which leads to a skull lowing measures: height 75 cm (>3rd percentile), weight malformation known as trigonocephaly [4]. There is insuffi- 9.6 kg (>3rd percentile) and head circumference 46 cm cient knowledge about the genes that affect the formation of (>3rd percentile) with prominent forehead and relative micro- the base of the skull, the premature fusion of the metopic cephaly. Her face shows a peculiar dysmorphism with the fol- suture leads to the deformation of the anterior calvarium caus- lowing features: a round face with prominent forehead, ocular ing keel shaped deformity of the forehead, dysmorphic facial area with arched eyebrows, slight upward palpebral fissures features, variable mental retardation and other somatic and and widely spaced eyes; nasal area with wide and depressed cerebral congenital anomalies [5]. The unusual face present nasal bridge, short and bulbous nose with anteverted nares, at birth includes eyes with upslanting palpebral fissures and and broad smooth philtrum (Fig. 2); the ears have a low posi- ocular hypertelorism, nose with depressed nasal bridge and tion, the mouth has a thin upper lip with tented vermillion and long philtrum; mouth with thin upper lip, and frequently the a broad lower lip; the jaw is narrow and there is a small chin ears are in a low position [6]. The inheritance has been (Fig. 3). The neurological examination detected a mild gener- assumed to be autosomal recessive; then the syndrome is con- alized hypotonia, clumsiness and awkward movements, global sidered heterogeneous genetic disorder, predominantly spo- developmental delay with verbal and nonverbal disabilities. radic but with sufficient familial cases [7] that may suggest Her phenotype is a mild form of the syndrome with no severe dominant mutations with a rate of germinal mosaicism, or visceral anomalies but has limb abnormalities like the small the presence of a recessive genocopy [8]. hands 8.5 cm (3rd percentile) with shortening of metacarpals and phalanges, and camptodactyly (cannot be extended) and 2. Case report clinodactyly (curved in the plane of the palm) of bilateral fifth fingers; she has small feet with measure of 11 cm (10th per- We report a 4-year-old girl with the main manifestations of centile) and there is an overlapping toe in the right foot, the Opitz C syndrome: mild motor and mental retardation, fourth toe is dorsally positioned over the third (Fig. 4). The trigonocephaly and craniofacial dysmorphic features; that cytogenetic analysis using standard technique with banded are the principal criteria for diagnosis. The family history metaphase chromosomes at the 500–750 band resolution was was unremarkable; the marriage was non-consanguineous, 46,XX karyotype; but FISH analysis showed balanced translo- the paternal age was 45, the maternal age was 36; the patient cation between chromosomes two and eleven: t(2:11) had other two siblings: an elder brother 18-year-old and a sis- (q32.2/q24). ter 11-year-old, all the family members were apparently healthy. The mother reported no exposure to teratogens and 3. Discussion she did not drink any alcohol during the pregnancy. The new- born was obtained from 38 weeks of gestation, by cesarean The C Opitz syndrome is a cerebral and craniofacial disorder, section because of severe neonatal hypoxia before and during a very rare genetic disease and still under-recognized, the birth. The baby was considered small for her gestational age, reviewed clinical criteria for diagnosis comprise: trigono- the birth weight was 2525 g (7th percentile), length 41 cm cephaly with dysmorphic face, in patients with cerebral defects (3rd percentile), and head circumference 32 cm (3rd per- that have severe mental retardation [9]; the main dysmorphic centile), the Apgar scores were 8 and 9. At birth was detected features are the upward slanting palpebral fissures, ocular cranial anomaly with middle frontal protuberance with a trian- hypertelorism; depressed nasal bridge with hypoplasy of the gular shaped forehead, it was diagnosed as congenital trigono- nasal root, short nose with anteverted nares; smooth and cephaly. She had a mild delay in psychomotor development, broad philtrum, small ears in low position, and mouth with including speech delay and early motor development retarded; thin upper lip [10]. The syndrome has no chromosomal abnor- she rolled over at age 7 months, had the head control at mality defined in the usual karyotype suggesting that this 9 months, and learned to sit independently at the age of 1, disorder may be a microdeletion syndrome which is cytogenet- she stood momentarily without support at the age of 2; but ically detectable only with fluorescence in situ hybridization the patient cannot walk. The speech development had a severe (FISH) that can